Saturday, August 11, 2007


This one's been simmering in my brain for a while. With our sidebar voters telling us they like psychotherapy posts, I figured it was a good time.

So my very confabulated patient comes to therapy in a state of acute distress. His wife died unexpectedly only weeks before; he is tearful, angry, and sad with heart-wrenching poignance. He's lost his appetite, he pines for her, he misses her and sometimes things as trivial as a commercial she'd commented on will make him burst into tears. On the flip side, he's back at work, taking care of his kids and their needs, and while he's distraught, he's not feeling guilty or suicidal or having anything very strange happen. He has no history of psychiatric disorder and he has a lot of support from family and friends. While everyone is concerned and trying to help him cope, no one has commented that his reaction to this tragic event is any thing other than what one might expect. In a word, the patient is grieving.

Acute grief alone is not usually a reason people seek psychiatric treatment. I listen, I offer some reassurances, and while I'm happy to be there for him, there is not much to do. Time will help. Time will help a lot, but it may take a lot of time.

"What made you feel you needed to see a psychiatrist?" I asked. I tried to say it gently, not as What You Doing Here? but simply as a question of Is There More To This?

"Losing my wife," he said, "Has brought up some old stuff for me."

His stories poured out. It was a difficult one with lots of early losses, family chaos with some periods in foster care, neglect and abuse. A lot of struggles, and a lot of room to create psychopathology. But there was none-- this was a man who owned his own business, had devoted employees and friends, a single marriage of many years, children of whom he was proud, in short-- a full and functional life. That's not to say there hadn't been hard times or that he'd never struggled as an adult, or even that life was perfect, but he didn't have a mental illness and he was able to love, work, and sustain meaningful relationships.

The question, I thought, and maybe I even said it, wasn't why this man was having problems now, it was why hadn't he had problems before.

"You've had a lot to deal with, " I said (--that's about as profound as I get).

"Yeah, but what can you do? I'm not much for dwelling in the past, but lately, I've been thinking about this stuff again."

He's right, of course, that if one can put the past aside and deal with life as it comes, that's better. It's when the past gets in the way of the present and future, or when the patient just can't move on, that it becomes mandatory to explore it in therapy. I'm left to wonder, though, why some people are crippled by stories that don't sway so far from the norm of what life deals, and others soar after enduring the extremes.

He came for a while, told his stories, grieved intensely. Mostly I listened, often I wanted to cry myself.